EXSC 2100 Final Exam

Circulatory and Neurological Function Test

-Pulse should be taken at brachial artery and radial artery -Skin sensation should be checked, determine presence of nerve root compression or irritation in cervical or shoulder region Tinel's sign -Ulnar nerve test -Tap on ulnar nerve (in ulnar groove) -Positive test is found when athlete complains of sensation along the forearm and hand

Functional Evaluation of the Wrist Hand and Fingers

-Range of motion in all movements of wrist and fingers should be assessed -Active, resistive and passive motions should be assessed and compared bilaterally -Wrist - flexion, extension, radial and ulnar deviation -MCP joint - flexion and extension -PIP and DIP joints - flexion and extension -Fingers - abduction and adduction -MCP, PIP and DIP of thumb - flexion and extension -Thumb - abduction, adduction and opposition -5th finger - opposition

Lunotriquetral Ballottement Test

-Stabilize lunate while sliding the triquetral anteriorly and posteriorly -Assessing laxity, pain and crepitus -Positive test indicates instability that often results in dislocation of the lunate

Recognition and Management of Injuries to the Elbow

-Subject to injury due to broad range of motion, weak lateral bone structure, and relative exposure to soft tissue damage -Many activities place excessive stress on joint -Locking motion of some activities, use of implements, and involvement in throwing motion make elbow extremely susceptible

Phalen's Test

-Test for carpal tunnel syndrome -Position is held for approximately one minute -If test is positive, pain will be produced in region of carpal tunnel

Finklestein's Test

-Test for de Quervain's syndrome -Athlete makes a fist w/ thumb tucked inside -Wrist is ulnarly deviated -Positive sign is pain indicating stenosing tenosynovitis -Pain over carpal tunnel could indicate carpal tunnel syndrome

Test for Capsular Injury

-Tested after hyperextension of elbow -Elbow is flexed to 45 degrees, wrist is fully flexed and extended -If joint pain is severe, moderate/severe sprain or fracture should be suspected (chronic injury may present same)

Valgus/Varus and Glide Stress Tests

-Tests used to assess ligamentous integrity of joints in hands and fingers -Valgus and varus tests are used to test collateral ligaments -Anterior and posterior glides are used to assess the joint capsule

Prevention of Elbow Injuries

-The elbow is vulnerable to acute traumatic and chronic overuse injuries -Acute injuries usually occur from a direct blow or falling on an outstretched hand. -Strategies for reducing chronic injuries -Limit the number of repetitions in throwing a baseball or in hitting a tennis ball -Ensure that the mechanics of the throwing or hitting techniques being used are correct -Select and use equipment that is appropriate for a specific skill level -The athlete should maintain appropriate levels of strength and endurance in the muscles surrounding the elbow by engaging in strength training. He or she should routinely stretch the muscles in the elbow, forearm, and wrist to make certain that they have the necessary flexibility to allow movement through a full range of motion. If a chronic overuse problem seems to be developing, the athlete should take some time off and give the injury a chance to heal before it gets worse.

Empty Can Test

90 degrees of shoulder flexion, internal rotation and 30 degrees of horizontal abduction Downward pressure is applied Weakness and pain are assessed bilaterally for supraspinatus

Apprehension tests

Apprehension test used for anterior glenohumeral instability  Posterior instability apprehension test

Peripheral Nerve Injuries

Etiology -Blunt trauma or stretch type injury Signs and Symptoms -Constant pain, muscle weakness and paralysis or atrophy

Sprains of Interphalangeal Joints

Etiology -Can include collateral ligament, volar plate, extensor expansion tears -Occurs w/ axial loading or valgus/varus stresses Signs and Symptoms -Pain, swelling, point tenderness, instability -Valgus and varus tests may be positive

Tenosynovitis

Etiology -Cause of repetitive wrist accelerations and decelerations -Repetitive overuse of wrist tendons and sheaths Signs and Symptoms -Pain w/ use or pain in passive stretching -Tenderness and swelling over tendon

Extensor Tendon Avulsion (Mallet Finger)

Etiology -Caused by a blow to tip of finger avulsing extensor tendon from insertion -Also referred to as baseball or basketball finger Signs and Symptoms -Pain at DIP; X-ray shows avulsed bone on dorsal proximal distal phalanx -Unable to extend distal end of finger (carrying at 30 degree angle) -Point tenderness at sight of injury

Dislocation of the Elbow

Etiology -Caused by fall on outstretched hand w/ elbow extended or severe twist while flexed -Bones can be displaced backward, forward, or laterally -Distinguishable from fracture because lateral and medial epicondyles are normally aligned w/ shaft of humerus Signs and Symptoms -Swelling, severe pain, disability -Complications w/ median and radial nerves and blood vessels -Often a radial head fracture is involved

Scaphoid Fracture

Etiology -Caused by force on outstretched hand, compressing scaphoid between radius and second row of carpal bones -Often fails to heal due to poor blood supply Signs and Symptoms -Swelling, severe pain in anatomical snuff box -Presents like wrist sprain -Pain w/ radial flexion

Little League Elbow

Etiology -Caused by repetitive microtraumas that occur from throwing (not type of pitch) -May result in numerous disorders of growth in the pitching elbow -Linked to: -Accelerated apophyseal growth region and delay in medial epicondyle growth plate -Traction apophysitis with possible fragmentation of medial epicondylar apophysis -Avulsion of medial epicondyle or radial head -Osteochondrosis of humeral capitellum -Non-union stress fracture of olecranon epiphysis Signs and Symptoms -Onset is slow; slight flexion contracture, including tight anterior joint capsule and weakness in triceps -Patient may complain of locking or catching sensation -Decreased ROM of forearm pronation and supination

Shoulder Bursitis

Etiology -Chronic inflammatory condition due to trauma or overuse - subacromial bursa -Fibrosis, fluid build-up resulting in constant inflammation Signs and Symptoms -Pain w/ motion and tenderness during palpation in subacromial space; positive impingement tests

Thoracic Outlet Compression

Etiology -Compression of brachial plexus, subclavian artery and vein due to 1) decreased space between clavicle and first rib, 2) scalene compression, 3) compression by pec. minor, or 4) presence of cervical rib Signs and Symptoms -Paresthesia and pain, sensation of cold, impaired circulation, muscle weakness, muscle atrophy and radial nerve palsy -Positive anterior scalene test, costoclavicular test and hyperabduction test

Metacarpal Fracture

Etiology -Direct axial force or compressive force -Fractures of the 5th metacarpal are associated w/ boxing or martial arts (boxer's fracture) Signs and Symptoms -Pain and swelling; possible angular or rotational deformity

Contusion of Upper Arm

Etiology -Direct blow Signs and Symptoms -Transitory paralysis and inability to use extensor muscles of forearm (if radial nerve impacted)

Swan Neck Deformity and PsuedoBoutonniere Deformity

Etiology -Distal tear of volar plate may cause Swan Neck deformity; proximal tear may cause PsuedoBoutonniere deformity Signs and Symptoms -Pain, swelling w/ varying degrees of hyperextension -Tenderness over volar plate of PIP -Indication of volar plate tear = passive hyperextension

Fractures of the Elbow

Etiology -Fall on flexed elbow or from a direct blow -Fracture can occur in any one or more of the bones -Fall on outstretched hand often fractures humerus above condyles or between condyles -Condylar fracture may result in gunstock deformity -Direct blow to olecranon or radial head may result in fracture Signs and Symptoms -May not result in visual deformity -Hemorrhaging, swelling, muscle spasm

Clavicular Fractures

Etiology -Fall on outstretched arm, fall on tip of shoulder or direct impact -Occur primarily in middle third (greenstick fracture often occurs in young patients) Signs and Symptoms -Generally presents w/ supporting of arm, head tilted towards injured side w/ chin turned away -Clavicle may appear lower -Palpation reveals pain, swelling, deformity and point tenderness

Glenohumeral Joint Sprain

Etiology -Forced abduction and/or external rotation or a direct blow Signs and Symptoms -Pain during movement especially when re-creating MOI -Decreased ROM and pain w/ palpation

Dislocation of Lunate Bone

Etiology -Forceful hyperextension or fall on outstretched hand Signs and Symptoms -Pain, swelling, and difficulty executing wrist and finger flexion -Numbness/paralysis of flexor muscles due to pressure on median nerve

Forearm Splints

Etiology -Forearm strain - most come from severe static contraction Signs and Symptoms -Dull ache between extensors which cross posterior aspect of forearm -Weakness and pain w/ contraction -Point tenderness in interosseus membrane

Fractures of the Humerus

Etiology -Humeral shaft fractures -Occur as a result of a direct blow, or fall on outstretched arm -Proximal fractures occur due to direct blow, dislocation, fall on outstretched arm -May pose danger to nerve and blood supply -Epiphyseal fractures are more common in young patients -Occurs due to direct blow or indirect blow travelling along long axis of humerus Signs and Symptoms -Pain, swelling, point tenderness, decreased ROM

Sternoclavicular Sprain

Etiology -Indirect force, blunt trauma (may cause displacement) Signs and Symptoms Grade 1 - pain and slight disability Grade 2 - pain, subluxation w/ deformity, swelling and point tenderness and decreased ROM Grade 3 - gross deformity (dislocation), pain, swelling, decreased ROM -Possibly life-threatening if dislocates posteriorly

Ulnar Collateral Ligament Injuries

Etiology -Injured as the result of a valgus force from repetitive trauma -Can also result in ulnar nerve inflammation, or wrist flexor tendinitis; overuse flexor/pronator strain, ligamentous sprains; elbow flexion contractures or increased instability Signs and Symptoms -Pain along medial aspect of elbow; tenderness over MCL -Associated paresthesia, positive Tinel's sign -Pain w/ valgus stress test at 20 degrees; possible end-point laxity -X-ray may show hypertrophy of humeral condyle, posteromedial aspect of olecranon, marginal osteophytes; calcification w/in MCL; loose bodies in posterior compartment

Muscle Strains

Etiology -MOI is excessive resistive motion (falling on outstretched arm), repeated microtears that cause chronic injury -Rupture of distal biceps is most common muscle rupture of the upper extremity Signs and Symptoms -Active or resistive motion produces pain; point tenderness in muscle, tendon, or lower part of muscle belly

Shoulder Impingement

Etiology -Mechanical compression of supraspinatus tendon, subacromial bursa and long head of biceps tendon due to decreased space under coracoacromial arch -Seen in over head repetitive activities -Exacerbating factors - laxity and inflammation, postural mal-alignments -kyphotic posture, rounded shoulders Signs and Symptoms -Diffuse pain, pain on palpation of subacromial space -In overhead athletes clinicians may see increased GH external rotation (ERG) and decreased internal rotation (GIRD) -Positive impingement and empty can tests

Wrist Sprains

Etiology -Most common wrist injury -Arises from any abnormal, forced movement -Falling on hyperextended wrist, violent flexion or torsion -Multiple incidents may disrupt blood supply Signs and Symptoms -Pain, swelling and difficulty w/ movement

Hamate Fracture

Etiology -Occurs as a result of a fall or more commonly from contact while athlete is holding an implement Signs and Symptoms -Wrist pain and weakness, along w/ point tenderness -Pull of muscular attachment can cause non-union

Bennett's Fracture

Etiology -Occurs at carpometacarpal joint of the thumb as a result of an axial and abduction force to the thumb Signs and Symptoms -CMC may appeared to be deformed - X-ray will indicate fracture -Patient will complain of pain and swelling over the base of the thumb

Colles' Fracture

Etiology -Occurs in lower end of radius or ulna -MOI is fall on outstretched hand, forcing radius and ulna into hyperextension -Less common is the reverse Colles' fracture (Smith fracture) -Anterior displacement of distal fragment -Intraarticular fracture is referred to as a Barton fracture Signs and Symptoms -Forward displacement of radius causing visible deformity (silver fork deformity) -When no deformity is present, injury can be passed off as bad sprain -Extensive bleeding and swelling -Tendons may be torn/avulsed and there may be median nerve damage

Medial Epicondylitis

Etiology -Repeated forceful flexion of wrist and extreme valgus torque of elbow -May involve pronator teres, flexor carpi radialis and ulnaris, and palmaris longus tendons -Can be associated with ulnar nerve neuropathy Signs and Symptoms -Pain produced w/ forceful flexion or extension -Point tenderness and mild swelling -Passive movement of wrist seldom elicits pain, but active movement does

Lateral Epicondylitis (Tennis Elbow)

Etiology -Repetitive microtrauma to insertion of extensor muscles of lateral epicondyle -Tendinosis with degeneration of tendon without inflammation Signs and Symptoms -Aching pain in region of lateral epicondyle after activity -Pain worsens and weakness in wrist and hand develop -Elbow has decreased ROM; pain w/ resistive wrist extension

Tendinitis

Etiology -Repetitive pulling movements of (commonly) flexor carpi radialis and ulnaris; repetitive pressure on palms (cycling) can cause irritation of flexor digitorum -Primary cause is overuse of the wrist Signs and Symptoms -Pain on active use or passive stretching -Isometric resistance to involved tendon produces pain, weakness or both

Contusion and Pressure Injuries of Hand and Fingers

Etiology -Result of blow or compression of bones w/in hand and fingers Signs and Symptoms -Pain and swelling of soft tissue

Acromioclavicular Sprain

Etiology -Result of direct blow (from any direction), upward force from humerus, -Can be graded from 1-6 depending on severity Signs and Symptoms Grade 1 - point tenderness and pain w/ movement; no disruption of AC joint Grade 2 - tear or rupture of AC ligament, partial displacement of lateral end of clavicle; pain, point tenderness and decreased ROM (abduction/adduction) Grade 3 - Rupture of AC and CC ligaments Grade 4 - posterior separation of clavicle Grade 5 - loss of AC and CC ligaments; tearing of deltoid and trapezius attachments; gross deformity, severe pain, decreased ROM Grade 6 - displacement of clavicle behind the coracobrachialis

Scapular Fractures

Etiology -Result of direct impact or force transmitted up through humerus Signs and Symptoms -Pain during shoulder movement as well as swelling and point tenderness

Boutonniere Deformity

Etiology -Rupture of extensor expansion dorsal to the middle phalanx -Tendon slides below axis of PIP jointForces DIP joint into extension and PIP into flexion Signs and Symptoms -Severe pain, obvious deformity and inability to extend DIP joint -Swelling, point tenderness

Flexor Digitorum Profundus Rupture (Jersey Finger)

Etiology -Rupture of flexor digitorum profundus tendon from insertion on distal phalanx -Often occurs w/ ring finger when athlete tries to grab a jersey Signs and Symptoms -DIP can not be flexed, finger remains extended -Pain and point tenderness over distal phalanx

Gamekeeper's Thumb

Etiology -Sprain of UCL of MCP joint of the thumb -Mechanism is forceful abduction of proximal phalanx occasionally combined w/ hyperextension Signs and Symptoms -Pain over UCL in addition to weak and painful pinch

de Quervain's Disease (Hoffman's disease)

Etiology -Stenosing tenosynovitis in thumb (extensor pollicis brevis and abductor pollicis longus -Constant wrist movement can be a source of irritation Signs and Symptoms -Aching pain, which may radiate into hand or forearm -Positive Finklestein's test -Point tenderness and weakness during thumb extension and abduction; painful catching and snapping

Acute Subluxations and Dislocations

Etiology -Subluxation involves excessive translation of humeral head w/out complete separation from joint -Anterior dislocation is the result of an anterior force on the shoulder, forced abduction and external rotation -Posterior dislocation occurs due to forced adduction and internal rotation or falling on an extended and internally rotated shoulder Signs and Symptoms -Anterior inferior dislocation - flattened deltoid, prominent humeral head in axilla; arm carried in slight abduction and external rotation; moderate pain and disability -Posterior dislocation - severe pain and disability; arm carried in adduction and internal rotation; prominent acromion and coracoid process; limited external rotation and elevation

Olecranon Bursitis

Etiology -Superficial location makes it extremely susceptible to injury (acute or chronic) --direct blow Signs and Symptoms -Pain, swelling, and point tenderness -Swelling will appear almost spontaneously and w/out usual pain and heat

Wrist Ganglion

Etiology -Synovial cyst (herniation of joint capsule or synovial sheath of tendon) -Generally appears following wrist strain Signs and Symptoms -Appear on back of wrist generally -Occasional pain w/ lump at site -Pain increases w/ use -May feel soft, rubbery or very hard

Chronic Recurrent Instabilities

Etiology -Traumatic, atraumatic, microtraumatic (repetitive use), congenital and neuromuscular -As supporting tissue become more lax, mobility increases resulting in damage to other soft tissue structures

Forearm Contusion

Etiology -Ulnar side receives majority of blows due to arm blocks -Can be acute or chronic -Result of direct contact or blow Signs and Symptoms -Pain, swelling and hematoma -If repeated blows occur, heavy fibrosis and possibly bony callus could form w/in hematoma

Elbow Contusion

Etiology -Vulnerable area due to lack of padding -Result of direct blow or repetitive blows Signs and Symptoms -Swelling (rapidly after irritation of bursa or synovial membrane)

Forearm Fractures

Etiology -Common in youth due to falls and direct blows -Ulna and radius generally fracture individually -Fracture in upper third may result in abduction deformity due pull of pronator teres -Fracture in lower portion will remain relatively neutral -Older patients may experience greater soft tissue damage and greater chance of paralysis due to Volkmann's contracture Signs and Symptoms -Audible pop or crack followed by moderate to severe pain, swelling, and disability -Edema, ecchymosis w/ possible crepitus

Biceps Brachii Rupture

Etiology -Result of a powerful contraction -Generally occurs near origin of muscle at bicipital groove Signs and Symptoms -Patient hears a resounding snap and feels sudden and intense pain -Protruding bulge may appear near middle of biceps -Definite weakness with elbow flexion and supination

Tests for Glenohumeral Instability

Glenohumeral Translation -Anterior and posterior stability -Translation of 1cm or greater is an indication of GH ligament instability and inadequacy of glenoid lip Anterior and posterior drawer tests -Positive anterior and posterior drawer test indicates insufficiency of anterior and posterior joint capsule and labrum, respectively Sulcus test

Scapulohumeral Rhythm

Movement of scapula relative to the humerus Initial 30 degrees of glenohumeral abduction does not incorporate scapular motion (setting phase) After the initial 30 degrees of abduction, there is a 2:1 ratio between glenohumeral and scapulothoracic joint motion

Test for Shoulder Impingement

Neer's test and Hawkins-Kennedy test for impingement used to assess impingement of soft tissue structures Positive test is indicated by pain and grimace

Test for Acromioclavicular Joint Instability

Palpate for displacement of acromion and distal head of clavicle Apply pressure in all 4 directions to determine stability

Relocation test

Relocation test uses external rotation and posteriorly directed pressure to allow for increased external rotation

Chronic Recurrent Instabilities of the Shoulder

Signs and Symptoms -Anterior - may have clicking or pain; complain of dead arm during cocking phase (when throwing); pain posteriorly; possible impingement; positive apprehension test -Posterior - possible impingement, loss of internal rotation; crepitation; increased laxity; pain anteriorly and posteriorly -Multidirectional - inferior laxity; positive sulcus sign; pain and clicking w/ arm at side; possible signs and symptoms associated w/ anterior and posterior instability

Throwing Mechanics

Windup Phase -First movement until ball leaves gloved hand -Lead leg strides forward while both shoulders abduct, externally rotate and horizontally abduct Cocking Phase -Hands separate (achieve max. external rotation) while lead foot comes in contact w/ ground Acceleration -Max external rotation until ball release (humerus adducts, horizontally adducts and internally rotates) -Scapula elevates, abducts and rotates upward Deceleration Phase -Point from ball release until max shoulder internal rotation -Eccentric contraction of ext. rotators to decelerate humerus while rhomboids decelerate scapula Follow-Through Phase -End of motion when athlete is in a balanced position

Test for Sternoclavicular Joint Instability

With patient seated, pressure is applied to the SC joint anteriorly, superiorly and inferiorly to determine stability or pain associated w/ a joint sprain

Test for Biceps Irritation

Yergason's test and Speed's test utilized to determine pain and possible subluxation of biceps tendon Ludington's test used to assess possible rupture of biceps (feel for contraction while alternating contractions of each biceps)

Valgus/Varus Stress Test

-Assess injury to the medial and lateral collateral ligaments, respectively -Looking for gapping or complaint of pain

Possible Complications of Shoulder Dislocations

-Bankart lesion - permanent anterior defect of labrum -Hill Sachs lesion - caused by compression of cancellous bone against anterior glenoid rim creating a divot in the humeral head -SLAP lesion - defect in superior labrum that begins posteriorly and extends anteriorly impacting attachment of long head of biceps on labrum -Brachial nerves and vessels may be compromised -Rotator cuff injuries -Fractures -Bicipital tendon subluxation and transverse ligament rupture

Fingernail Deformities

-Changes in normal appearance of the fingernail can be indicative of a number of different diseases -Scaling or ridging = psoriasis -Ridging and poor development = nutritional deficiencies -Clubbing and cyanosis = congenital heart disorders or chronic respiratory disease -Spooning or depression = thyroid problems, iron deficiency anemia

Functional Anatomy of the Elbow

-Complex that allows for flexion, extension, pronation and supination -145 degrees of flexion and 90 degrees of supination and pronation -Bony limitations, ligamentous support and muscular stability at the elbow help to protect it from overuse and traumatic injuries -Elbow demonstrates a carrying angle due to distal projection of humerus -Normal in females is 10-15 degrees, males 5 degrees -Critical link in kinetic chain of upper extremity

Pain and weakness are evaluated through AROM, PROM and RROM

-Flexion, extension, pronation and supination -ROM of pronation and supination are particularly noted

Circulatory and Neurological Evaluation of the Wrist Hand and Fingers

-Hands should be felt for temperature -Cold hands indicate decreased circulation -Pinching fingernails can also help detect circulatory problems (capillary refill) -Allen's test can also be used -Patient is instructed to clench fist 3-4 times, holding it on the final time -Pressure applied to ulnar and radial arteries -Patient then opens hand (palm should be blanched) -One artery is released and should fill immediately (both should be checked) -Hand's neurological functioning should also be tested (sensation and motor functioning)

Tinel's Sign

-Produced by tapping over transverse carpal ligament -Tingling, paresthesia over sensory distribution of the median nerve indicates presence of carpal tunnel syndrome

Blood and Nerve Supply to FWHF

-Most of the flexors are supplied by the median nerve -Most of the extensor are controlled by the radial nerve -Blood is supplied by the radial and ulnar arteries

Rotator cuff tear

-Occurs near insertion on greater tuberosity -Partial or complete thickness tear -Full thickness tears usually occur in those athletes w/ a long history (generally does not occur in athlete under age 40) -Primary mechanism - acute trauma or impingement -Involve supraspinatus or rupture of other rotator cuff tendons

Test for Serratus Anterior Weakness

Wall push-up - looking for winging scapula Could indicate injury to long thoracic nerve